Inspection on 26/01/06 for 8 St Winifred`s Road

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

8 St Winifred`s Road 17/07/08

8 St Winifred`s Road 16/01/07

8 St Winifred`s Road 15/09/05

8 St Winifred`s Road 21/10/04

8 St Winifred`s Road 16/04/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 8 St Winifred`s Road Shirley Southampton Hampshire SO16 6HP Lead Inspector Christine Hemmens Unannounced Inspection 26th January 2006 10:00 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 8 St Winifred`s Road Address Shirley Southampton Hampshire SO16 6HP 023 8070 5506 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) H4mo12tauarez@mencap.org.uk www.mencap.org.uk Royal Mencap Society Mrs Ann Marie Tavarez Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 2005 Brief Description of the Service: 8 St Winifred’s Road is a large detached family home situated in a quiet cul-desac close to Shirley High Street and local amenities. The home is registered to accommodate 8 residents with learning disabilities between the ages of 18 65. The current residents are all over the age of 30. Hyde Housing Association owns the property and Mencap manage the services. The manager has recently been registered with the Commission for Social Care Inspection. The home comprises eight single bedrooms, which are spacious and suitably furnished. There is a lounge, lounge/dining room and large kitchen and the home has a rear garden for recreational use. 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced visit to the home in the last twelve months. The manager, a member of staff and three residents assisted the inspector with the inspection. The inspector viewed residents’ personal records, house records and an environmental check of the building was undertaken. What the service does well: The service has done well to meet all but one of the requirements issued following the previous visit to the home. This demonstrates the manager takes seriously her role in ensuring the home is meeting the national minimal standards and positive outcomes for the residents. The service does well to support the residents in their daily lives in the way that they wish. It offers choices, support with decision-making and provides them with everyday opportunities and activities to develop and maintain personal skills, social skills and relationships. A resident informed the inspector that he liked living at 8 St Winifred’s because it was nice and the food is good, “I get to choose the food I like”. In respect of the residents’ health and wellbeing the home does well to support the residents to access and attend health care appointments and access specialist health care services if required. The service does well to provide an environment that is open and inclusive and as far as feasibly possible safe for the residents to live. One resident informed the inspector “the staff are nice and they listen to me”, “they help me calm down when I am not feeling happy”. The home holds regular meetings with the residents to seek their views on how the home should be run, their likes and dislikes and things they would like to do or change. This demonstrates the service takes seriously its responsibilities in ensuring the outcomes for the residents are driven by them. The manager and her staff appear aware of their responsibilities in ensuring the safety of the residents and adhere to their own and the local authorities polices and procedures on the protection of vulnerable adults. The service does well to provide a comfortable, welcoming, clean and wellmaintained home for the residents to live. Residents are encouraged to make choices about the décor and how they would like their to decorate and personalise their bedrooms. As far as feasibly possible the manager ensures the home is made safe for the residents and carries out regular checks and services on the homes equipment and utilities. The manager does well to deploy her staff appropriately and ensure they are equipped to meet the needs of the residents. The staff with whom the inspector met with demonstrate good values and an understanding of the needs of the residents. One member of staff stated “I received a thorough induction when I started and have attended several training sessions since I started”. The service does well to employ a manager who has a wealth of experience of working with service users with learning disabilities. The manager demonstrates that she takes seriously her roles and responsibilities in ensuring 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 6 the home is well managed and the residents are well provided for. The manager demonstrates good practice in working hands on with the residents and acting as a role model for her staff. What has improved since the last inspection? What they could do better: The service clearly demonstrates that it will meet requirements made from previous inspections to meet minimum standards and continue to improve standards in the home, this was demonstrated by all but one for the requirements issued following the previous visit to the home being met, however the home is required for the third occasion to fix appropriate door closure on residents bedroom doors to prevent them from propping the doors open. The housing association has the responsibility of making improvements to the home, however the service has the responsibility of ensuring the residents safety at all times. The service could do better to ensure staff are provided with guidance on when to give “As required medications” to ensure that they are being given for the right ailment, behaviour, the right dose and at the right time. The staff must also receive training in the administration of eye drops. The service could do better to ensure its staff receives regular fire training and receives training in infection control. The kitchen is looking tired and worn and would benefit from refurbishment, however the manager is advised to seek advice from the appropriate regulatory authority for their suggestions and views. 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 7 The home does well to seek the views of the residents, quality audit the service, however the views of its staff, relatives and visitors to the home be sought and a copy of the annual quality report must be sent to the Commission for Social Care Inspection. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home undertakes an appropriate assessment process to establish if it can meet the holistic needs of the prospective resident. EVIDENCE: Following the last visit to the home, it was required to improve its assessment documentation by ensuring all information obtained by professionals and previous carers was entered onto the home’s own documentation. The inspector met with the manager who clearly described the process used to assess prospective residents and why all the information gathered is not added to the documentation until such time the resident has visited the home on a number of occasions. The manager gave an example why this is so, information recently provided for a resident was not a true reflection of the person and their needs and the service felt it important to establish for themselves without having their judgement clouded with information that could have persuaded them not to admit the resident to the home. The manager informed the inspector that the assessment process continues for a while after the resident has moved in and care plans are then devised around the areas of strengths and needs. Residents’ holistic needs are assessed and health care professionals are called upon if specific assessments are required. 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7 The home is adopting a person centred approach to meeting the needs of the residents. The home encourages and supports residents to make choices and decisions about their lives. EVIDENCE: The home holds individual personal information for all residents, providing information on the residents DOB, NOK, contact details for GP’s and other health care professionals and their care manager. The resident’s personal plans identify their strengths, their needs and areas of personal risk to them. Improvements to the plans and the risk assessments have been made since the previous visit to the home. The manager spoke at length regarding significant changes of health, welfare and behaviours of some of the residents since the passing on of a resident who was incompatible with more than one of the residents living in the home. The manager described this as having a considerable impact on the mood of the home and how the home is now managed on a day-to-day basis. During a previous visit to the home the inspector viewed three person centred plans with the residents concerned, they informed the inspector that the plans 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 11 did not reflect what their lives were currently like. The home has since made a start on developing personal plans with the residents in an accessible format that will assist their ability to understand. The manager and the staff member with whom the inspector spoke to were aware of the value of ensuring the plan fully reflects the wishes and desires of the resident, and the process used in developing the plans was in the way in which the residents wished it to be. This is valuable ongoing work and to be done at the residents pace, therefore there is no restricted timescale to complete the person centred plans, however the manager must have a clear strategy for working with the resident to establish their dreams, desires, likes dislikes future plans etc and a strategy for regularly reviewing progress and outcomes for the residents. However the manager is advised to include in the person centred plans the residents’ desired daily routine and ensure staff receive appropriate training in person centred planning. Through the course of the visit to the home the inspector observed residents going about their daily life and being encouraged to make decisions about what they wanted to do, where they wanted to go and what they wanted to eat. One resident informed the inspector that staff helped him to make choices when he needed it, however he was very clear that he could make his own choices when it came to mealtimes and shared in the decision making in putting a menu plan together. Through adopting a person centred approach to the health, welfare, social needs, religious beliefs, relationships and friendships of the residents the home will enable residents to have more empowerment and opportunities to make choices and decisions about their lives. 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15,16 and 17 The home has adopted a person centred approach that assists residents to make choices about their relationships, assist them to recognise their right and responsibilities and assist them to make healthy decisions about their diet and dietary needs. EVIDENCE: The manager spoke at length regarding the relationships between residents, residents and staff and relationships with family and friends. The manager informed the inspector that relationships within the home had much improved recently and residents appeared more at ease and tolerant of one another and inappropriate behaviours had significantly improved. The residents with whom the inspector spoke with were aware of the unfortunate circumstances regarding the death of a former resident but appeared comfortable with the situation. This demonstrates the importance of ensuring residents are compatible and they receive support where necessary to express their views before prospective residents move in. The home positively supports and encourages residents to maintain and develop relationships outside of the home and the manager provided many examples of this. The importance of relationships was also highlighted in a person centred plan the inspector 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 13 viewed and one residents spoke at length regarding his fondness for someone health had been close to for many years. The manager gave an example of how they have sustained the friendship despite the resident’s friend not wishing to visit the home anymore. The inspector observed the interactions between residents and staff and found these to be positive, relaxed, and respectful. A respectful camaraderie was observed between some residents and staff. The inspector observed through the course of the visit examples of residents being provided with support to make choices and decisions about their responsibilities, their rights and what they would like to do. For example a resident was reminded why it was important that he paid his rent and making judgements regarding his expenditure, another was supported to have their hair cut and another resident was supported to buy some toiletries urgently needed. The residents with whom the inspector spoke gave examples of their responsibilities within the home from laying and clearing the dining room table, helping to prepare the evening meal, cleaning the kitchen and sweeping the floor after mealtimes. One resident informed the inspector that they were provided with support to clean their room and do their laundry. The inspector spoke with two residents regarding the menu and the variety of food available to them. The residents informed the inspector that they were involved in planning the weekly menu and all had an opportunity to choose a main meal during the week, which is then put on the menu planner. The menu appeared well balanced and nutritious. From discussion the inspector established that the residents’ wishes were respected and an alternative is provided for those who do not like what’s on the menu for the day. Choices were observed being given at lunchtime and the member of staff responsible for preparing the lunches catered for several different requests. A resident informed the inspector “the food is good and you can choose what you want”. The manager informed the inspector that the home caters for residents with particular dietary requirements, will seek advice from the appropriate professionals if required and will regularly weigh and monitor the eating habits of some of the residents to monitor particular health care needs. Evidence of this was seen in resident’s personal plans. Residents are provided with assistance to eat their meals where required. 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. The home is making progress in adopting a person centred approach in supporting residents with their personal care, emotional and health care needs and their medication in the way they wish to be supported. However improvement is required to ensure residents are not put at risk by in appropriate administration of “as required medications” and risk of injury when administering eye drops. EVIDENCE: As stated in previously in this report the home is making progress in adopting a person centred approach in meeting the holistic needs of the residents this includes how the residents wish to be supported with their daily life activities their health and welfare and their medication. Care plans reflect the support the resident requires clearly and risk assessments are in place to address potential risks in various task such as bathing and supporting the residents when their behaviours challenge them and others. However as addressed in standard six the manager is advised to include in the residents, person centred plans their daily routines from getting up to going to bed. This will provide a consistency of care support. Through viewing personal plans, speaking with residents and staff the inspector was able to establish that the residents receive the appropriate primary and specialist health care they require. All the residents are registered 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 15 with a GP and dentist and those who require the optician and chiropodist are regularly reviewed. The home has close links with the specialist health care team such as psycharitrists, speech and language therapists and occupational therapists etc. The inspector met with resident who had recently suffered a serious injury. He explained how his injury had occurred and how the staff have supported him since his accident to manage his initial disability. This was supported by the manager who explained what they had done to support him and how they had called upon a member of the specialist health care team to ensure they were correctly meeting his needs. The home supports residents to take their medication, the home uses a dossett monitoring system, which is dispensed by a reputable high street pharmacist. The inspector found the procedures in checking and recording medication administered to be in good order, however the manager must ensure that those residents receiving “as required” (PRN) medications have care plans in place to advise staff when the medication must be given. Staff receive medication administration training and are unable to administer the medication until they are deemed competent to do so, however the home supports residents with the administration of eye drops which staff do not receive training in. Due to the delicate operation of administering eye drops the manager must ensure all her staff receive training in this procedure. 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home provides information and an open and accessible environment for residents to raise their concerns. The home takes seriously all allegations of abuse and takes appropriate action in reporting, recording and ensuring residents are kept as safe as feasibly possible. EVIDENCE: The inspector met with a resident who had recently moved to the home, he stated he had settled in well and liked the residents, staff and the manager and felt happy to approach a member of staff or the manager if he had any concerns or wished to make a complaint. Following the previous visit to the home the manager was informed she must make accessible the complaints procedure for the residents, this has since been achieved, however some residents who didn’t wish to have this recorded in their personal plans. The inspector observed an open, relaxed and inclusive environment where general and advisory discussion took place throughout the course of the visit. Residents appeared happy and relaxed and the small number of residents the inspector spoke with said they were happy living at St Winifred’s. The inspector has established over the course of inspecting St Winifred’s that the home, its manager and staff understand their roles and responsibility in terms of ensuring the health safety and wellbeing of the residents. In addition staff receive regular training in abuse awareness and a member of staff was able to inform the inspector in detail what constituted abuse and what she would do in the event of discovering a resident had been harmed. However a number of events that have occurred in and outside of the home have meant the protection of vulnerable adult (POVA) procedures being instigated. On 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 17 each occasion the home has demonstrated that they have taken seriously the allegation, taken appropriate action and kept good records and specific actions have been carried out as required i.e. risk assessing the specific vulnerability. 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 The home provides a warm, comfortable and friendly environment for the resident to live. EVIDENCE: The home is a large pre-war building situated on the outskirts of Southampton City Centre. It has been tastefully decorated and furnished throughout. A separate lounge, dining room and kitchen provides amble space and an opportunity for the resident to choose where they want to spend their time whilst at home. Each resident has a room of their own decorated and furnished to their liking. There is an ongoing routine of redecoration and furnishing, the inspector was shown the newly decorated dining room and informed that residents had assisted in choosing the colour scheme. This was later confirmed by residents who said they liked the colours. The residents’ bedrooms reflect their individual character and interests and are homely and comfortable. The inspector spent time with one resident who proudly showed off his bedroom and informed the inspector that he preferred to be down stairs and that the room was to his liking. However another resident was not so pleased and stated he would prefer a bigger room. The manager is advised to discuss the resident’s concerns, with a possible option of moving the resident when 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 19 another room becomes available. The home has a large communal kitchen, which provides residents with the option to eat in the kitchen or dining room. The residents and staff take pride in keeping the kitchen clean and tidy, however the kitchen is looking worn and in need of refurbishment. This was evidenced by worn work tops, peeling and faded paintwork, cracks in walls and the smell of damp in some of the base cupboards. The manager informed the inspector that she had approached the housing association responsible for the maintenance of the building but had not been given a firm answer that the kitchen will be refurbished. The manager is advised to contact the appropriate regulatory authority in respect of the kitchen. The home has ample toilet and bathroom facilities, in addition the residents have hand washbasins in their bedrooms. The home is kept very clean and tidy and has good hygienic systems in place to minimise the risk of infection. However staff have not received training in infection control. The manager must ensure all her staff fully understands their roles and responsibilities with regards to infection control. The utility room is spacious, very clean and the facilities enable the residents to launder and iron their clothes with minimum support. However the following areas of concern identified at the time of the visit in relation to the home must be addressed. 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. The home ensures experienced staff and adequate staffing levels appropriately meet the needs of the residents, however further training is required to ensure residents are safely supported. The residents are now safe guarded from potential harm by appropriate recruitment procedures. EVIDENCE: The home is covered twenty fours a day and currently has eight staff including the manager, the manager stated she is expecting a new deputy to be starting soon. The manager produced evidence that she deploys her staff to effectively meet the needs of the residents and at the time of the visit the home appeared adequately staffed and residents were supported to go out individually throughout the day. The home uses “Team Mates” to back fill staff absences, these are staff employed by Mencap as relief staff. The home has an appropriate training programme to equip staff with the basic skills of supporting the residents and people with learning disabilities. The home provides mandatory training such as fire training and first aid and resident specific training such as the Learning Disability Award Framework and medication training, staff are also encouraged to undertake a National Vocational Award in care. However the inspector established by viewing fire records that staff had not had the mandatory two fire training sessions in twelve months therefore the manager is required to ensure staff receive fire 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 21 training without delay (This refers to standard 42, Health and Safety). Following the last visit to the home the manager was required to ensure staff receive training in person centred planning and report writing. The manager confirmed that steps were being taken to provide person centred planning training for staff and that all staff had previously received training in report writing. The manager accepts responsibility for not regularly auditing care plans and reports written by staff to ensure they have been done correctly, but advised the inspector that this now forms part of her weekly monitoring process. The manager also advised that further support and supervision would be provided to staff that are found not to have completed records correctly. The inspector met with a member of staff who confirmed that she had received a full and supportive introduction into the home, assisted by the manager, staff and residents. She stated she felt she had received adequate training to undertake her roles and responsibilities confidently. The inspector observed that the member of staff appeared relaxed and confident to support and engage with the residents. Following the previous visit to the home the manager was immediately required to take action to minimise the risk to residents posed by not undertaken a robust recruitment procedure and employing a member of staff before all checks had been received. The manager now demonstrates a clear understanding of her role in implementing a robust recruitment procedure, discussion with the manager and records produced at the time of the visit supports this. 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 The residents’ benefit from a well run home that listens to the views of the residents. The home attempts to safeguard the residents’ health, safety and welfare, however further work is required to ensure areas identified as a risk are addressed. EVIDENCE: The manager Mrs Tavarez has been the registered manager at 8 St Winifred’s for approximately ten months, however has a wealth of experience in supporting and working with residents with learning disabilities and has worked at 8 St Winifred Road for a number of years. The manager demonstrated that she is fully aware of the needs of the residents and provided the inspector with an individual report on the current health and welfare issues for each resident. The manager stated that she worked approximately twelve hours hands on care and support because “its important for me to know what is happening for the residents and provide support to staff”. 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 23 The manager also demonstrated that she understood the needs of her staff and through the course of the visit was observed to provide supportive advice and give clear instruction to them. The inspector was informed that the previous deputy manager had left but that it was hoped that an experience deputy manager would be joining the team soon. Through the course of the day the inspector observed staff and the manager being accessible, listening and providing supportive advice to the residents. One resident confirmed that he liked the staff because “they are nice” another when asked if the staff listen to him said “Yes and they know when I am not feeling happy and help me to calm down”. This demonstrates that the home provides a supportive environment that understands the needs of the residents. The manager informed the inspector that the home encourages the residents to attend three monthly meetings, to share their views, their ideas and things they like or dislike about the home. Minutes of the meeting are taken and provide evidence of who attended and what was discussed. The manager stated that the meetings are relaxed, informal and no set format is used. The minutes of the meeting seen by the inspector demonstrates that this is appears to be an appropriate approach. In addition to listening to the residents and holding meetings the service is quality audited monthly by another manager within Mencap. The service provides very good documentation for auditing the quality of the service and these are received monthly in the office of the Commission for Social Care Inspection, however the quality of the audit process must be improved to provide better information, such as seeking the views of residents and staff at the time of the visit. The Royal Mencap Society also has systems and procedures for quality auditing its services, involving the managers and supporting them to develop and implement a three-year strategic plan. A thorough plan was seen by the inspector, however the home/service must consider sending the quality audit report (Regulation 24(2)) to the Commission for Social Care Inspection. The manager produced evidence that she takes seriously the health and safety of the residents and staff. Good record keeping, safe storage of corrosive substances hazardous to health (COSHH), safe storage and recording of foods, staff training and evidence of checks on fire equipment and service certificates for utilities. However as stated in standard 30 and 35 staff must receive up to date training in fire procedures and infection control and the manager must ensure residents bedrooms doors are fitted with appropriate closures to prevent the risk of harm in the event of a fire. The manager was able to demonstrate through record keeping and making telephone calls at the time of the inspection that she has tried to meet the previously made requirement to fit appropriate closures. In the interim the manager must undertake risk assessments on those residents at potential risk. 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 1 X 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA42 Regulation 23(4)(c)(i) Requirement The registered manager after consultation with the fire authority must install appropriate devices to hold open residents bedroom doors. Designated fire doors must not be held open by any means other than approved devises linked to the fire alarm system. This requirement has been repeated for a third time. A further failure to comply will result in enforcement action taking place. 2 YA35 YA42 23(4) 18 The registered manager must ensure all staff receives regular training in the prevention, detecting and evacuation in the event of a fire. The first training must be scheduled by the stated timescale. The registered manager must ensure staff receive training in the administration of eye drops. The registered manager must ensure all residents receiving DS0000011806.V280884.R01.S.doc Timescale for action 01/03/06 31/03/06 3 4 YA35YA20 YA20 13(2) 18 13(2) 09/04/06 31/03/06 8 St Winifred`s Road Version 5.1 Page 26 6 YA24 23 “as required” medications have protocols in place for their administration, i.e. to indicate when and at what point the medication is needed, correct dose etc. The registered manager must seek advice from the appropriate regulatory body regarding the concerns raised about the home’s kitchen. The registered manager must ensure her staff are trained in infection control. 30/04/06 7 YA30YA35 18 23 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard Good Practice Recommendations YA7/YA6/YA16/YA13 The registered manager is advised to review residents person centred plans along side the personal plans on a monthly basis. Recording outcomes. YA7/YA6/YA16/YA13 The registered manager is advised to include in the residents’ person centred plans their daily routines. YA39 The registered manager is advised when carrying out regulation 26 visits that she seeks the views of residents and staff and clearly records actions. YA39 The registered manager is advised to consider sending to the Commission for Social Care Inspection the outcome of quality audits undertaken with residents, staff, relatives and professionals. 2 3 4 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 8 St Winifred`s Road DS0000011806.V280884.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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